Eso deviation

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Binocular Vision

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Eso deviation

  1. 1. ESO DEVIATION Prepared by: Anis Suzanna Binti Mohamad Optometrist B.Sc (Hons) UKM
  2. 2. Different type of deviations Convergent Squint Divergent Squint Vertical Squint
  3. 3. ESOTROPIA
  4. 4. Eso Deviation Eso Tropia Phoria 1° 2 ° Consec. i. Conv. Excess Constant ii. Div. Weakness i. withAccom. Elem. iii. Non-specific ii. without Accom. Elem. Intermittent i.Accom. ii. Distance - near eso - distance eso iii. Time - cyclic/alternate day squint iv. Non-specific
  5. 5. Fully Accom. Esotropia Normal BSV for all distances when hypermetropia is corrected. Manifest convergent dev. – without hypermetropic correction.
  6. 6. Fully Accom. Esotropia Aetiology : Low uncorrected hypermetropia (<3DS) - squint not develop if patient has sufficient base in fusional vergences. Moderate degrees hypermetropia (3-5DS) – amount of NFR not enough to overcome conv.→ esotropia. High degree hypermetropia (>5DS) – insuperable hypermetropia – patient remain straight or occasionally diverge.
  7. 7. Fully Accom. Esotropia Investigation : Age of onset – 2-3 years old – starts to be interested in close work. FH Refraction VA – may be reduced in deviating eye. Hirschberg CT – with and without glasses. OM Convergence – with glasses – binoc. to 6cm.
  8. 8. Fully Accom. Esotropia - Strength of BSV – BVA, PFR, synopthophore. - PCT – with and without glasses.
  9. 9. Management -Prescribe fully hypermetropic lenses -Gls. worn full time -Occlusion – if amblyopia present -Orthoptic exercises – to strengthen BSV Fully Accom. Esotropia
  10. 10. Convergence Excess Esotropia Normal BSV at distance and esotropia on accommodation for near fixation. Aetiology : - *High AC/A ratio (5/6 times normal amount) - Remote near point of accom. - Onset – 3-5 years of age
  11. 11. Convergence Excess Esotropia Investigation : - Fundi and Media check - Refraction - VA – likely to be equal - CT - - OM - Convergence - Assessment of strength of BSV - PCT - AC/A ratio
  12. 12. Convergence Excess Esotropia Management : -Prescribe hypermetropic correction if required -Treat any amblyopia -Surgery -Other methods : - Bifocals – combine with orthoptic exercise - Contact lens
  13. 13. Near Esotropia - also known as non-accom. conv. excess eso - Manifest deviation at near (irrespective of accom.) and BSV at distance. - Aetiology : excess tonic convergence
  14. 14. Near Esotropia Investigation : - Fundi and Media check - Refraction - VA - CT - OM - Convergence - Assessment of BSV - PCT
  15. 15. Near Esotropia Management : - Surgery
  16. 16. Distance Esotropia - Manifest convergent deviation at distance - BSV at near - Has to be differentiated from mild 6th nerve palsy, Accom./convergence spasm and divergence paralysis.
  17. 17. Distance Esotropia Investigation : - Fundi and Media check - Refraction - VA - CT - OM - Convergence - Assessment of BSV - PCT
  18. 18. Distance Esotropia Management : - rare type of deviation - Important to differentiate from mild 6th nerve palsy. - Surgery done generally : Bilateral LR resection.
  19. 19. Primary Cyclic Esotropia Esotropia occurs at regular intervals (48hrs) Onset : 4-5 years old Emmetropic and equal VA Management : - deviation generally becomes more constant. - Surgery : MR recess + LR resect - Prognosis : good, even when surgery done on straight day.
  20. 20. Primary Constant Esotropia Esotropia with accom. Element - eso increase on accom. - eso may be reduced with any necessary hypermetropic correction. - also known as partial accom. esotropia.
  21. 21. Primary Constant Esotropia Esotropia without accom. Element - deviation unaffected by accom. - significant ref. error unlikely to be present - Types : infantile esotropia, acquired non-accom. esotropia, nysragmus blockage syndrome, normo-sensorial late onset esotropia.
  22. 22. Primary Constant Esotropia Normosensorial late onset esotropia - onset – 2-4 years of age - NRC - normal sensory and motor fusion Management : - Surgery – when dev. Stable (if indicated).
  23. 23. Primary Constant Esotropia Nystagmus Blockage syndrome - use conv. to block manifest nystagmus - Nystagmus – congenital, horizontal, manifest. - Nystagmus – increase in intensity on abduction and blocked on adduction. - Esotropia – non-accom., variable. - Face turn towards fixing eye
  24. 24. Primary Constant Esotropia - BE appears conv. Though esotropia is unilat. - DVD rare - Commonly associated with neurological disorders. - Results of strabismus – unpredictable Management: - full correction - Treat amblyopia - Surgery
  25. 25. Primary Constant Esotropia General Investigation : Aim : - to make diagnosis - assess whether potential for BSV present. - gain further information to base management upon.
  26. 26. Primary Constant Esotropia - Fundi and Media check - Refraction - Case history - VA - CT - OM - Conv. - Suppression - Fixation
  27. 27. Primary Constant Esotropia Management : - Order any glasses necessary - Treat amblyopia - Determine if pot. BSV present : If present : - Prismotherapy - advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.
  28. 28. Primary Constant Esotropia - aim : to reduce ∆ - may be combine with surgery - Orthoptic treatment to strengthen BSV. If absent : - surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.
  29. 29. Essential Infantile Esotropia
  30. 30. Primary Constant Esotropia Essential Infantile Esotropia - onset : first 6 month of life - Esotropia of unknown origin - Stable large angle eso > 30PD - Alternating with crossed fixation - Poor prognosis of BSV
  31. 31. Primary Constant Esotropia - Commonly associated with DVD, o/action oblique muscles, AHP - Amblyopia if not alternating Management : - Full correction - Treat amblyopia - Surgery Primary Constant Esotropia
  32. 32. Primary Constant Esotropia General Investigation : Aim : - to make diagnosis - assess whether potential for BSV present. - gain further information to base management upon.
  33. 33. Primary Constant Esotropia - Fundi and Media check - Refraction - Case history - VA - CT - OM - Conv. - Suppression - Fixation
  34. 34. Primary Constant Esotropia Management : - Order any glasses necessary - Treat amblyopia - Determine if pot. BSV present : If present : - Prismotherapy - advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.
  35. 35. Primary Constant Esotropia - aim : to reduce ∆ - may be combine with surgery - Orthoptic treatment to strengthen BSV. If absent : - surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.
  36. 36. Secondary Esotropia Esotropia following loss/impairment of vision Blind at birth → convergent/divergent deviation Childhood blindness → convergent
  37. 37. Secondary Esotropia Possible cause : - Injuries - Corneal opacities - Congenital/Traumatic unilateral cataract - Optic Atrophy - Untreated anisometropia/amblyopia - Retinal detachment
  38. 38. Secondary Esotropia Aims of investigation : - Assess VA of each eye – dictates test can be carried out - Assess whether case is functional or cosmetic (2º dev. rarely functional) - Assess angle of deviation
  39. 39. Secondary Esotropia Investigation : - Refraction - History - VA - CT - OM - Measurement of the angle - State of BV (functional/cosmetic) - Post-op diplopia test Management : surgery
  40. 40. Consecutive Esotropia Esotropia in a patient who previously had an exotropia/exophoria. Generally occur as a result of surgery- immediate or long term.
  41. 41. Consecutive Esotropia Post-Operative Consecutive Esotropia - may be deliberate - may be due to over-liberal surgery e.g LR recession or MR resection. Management depend on whether the case is functional or cosmetic.
  42. 42. Consecutive Esotropia Aim : Functional cases : - To assess presence of diplopia - To assess angle of deviation - To assess any amblyopia present - To assess BF/pot. for BSV - To assess suppression
  43. 43. Consecutive Esotropia Cosmetic case : Ultimate aim – cosmeticaaly good angle without diplopia. - to assess angle of deviation - to assess any diplopia present - to assess suppression
  44. 44. Consecutive Esotropia Investigation : - Fundus and Media check - History – patient may return many years after original surgery. History relating previous treatment important. Read operation notes if available. Ask if patient has symptoms – diplopia. - VA – relate to vision pre-op.
  45. 45. Consecutive Esotropia - CT – assess with care. If control present at any distance-do BSV test at that distance. Note if diplopia appreciated – note the type. - OM – restriction, scars. Note if diplopia can be joined with AHP. - Convergence
  46. 46. Consecutive Esotropia - Suppression – density and area of suppression in functional case. Cosmetic case – if angle is small and suppressing – nothing to be done. If angle large and need resurgery – assess post-op diplopia test. - Measurement of angle – near and distance. If diplopia present – see if it can be joined with prism.
  47. 47. Consecutive Esotropia - AC/A ratio – in functional case –may influence type of treatment.

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